Do Strong Bones Require Weightlifting?

Joanne recently heard Dr. Belinda Beck speak about the Onero exercise program she developed for preventing osteoporotic fracture. Onero translates to "overload" in Latin — the program aims to progressively overload participants' bones (largely postmenopausal women with osteoporosis) using high resistance. Its genesis was the 2018 LIFTMOR trial.

What the LIFTMOR Trial Revealed. LIFTMOR (Lifting Intervention for Training Muscle and Osteoporosis Rehabilitation) was the first study comparing high-intensity resistance and impact training (HiRIT) against low-intensity exercise in postmenopausal women with low bone mass. 101 women were randomly assigned to different programs over 8 months. The HiRIT group did squats, deadlifts, overhead shoulder press, and jump chin-ups with drop landings, gradually progressed and supervised for safety; the control group did unsupervised, low-intensity home-based exercise. HiRIT showed superior bone density improvement with no fractures or major injuries reported (the only adverse event was a mild low-back strain), leading researchers to conclude it is "the first to show that a brief, supervised, twice-weekly HiRIT exercise intervention was efficacious and superior to previous programs for enhancing bone at clinically relevant sites... in postmenopausal women with low to very low bone mass." This challenges the assumption that osteoporosis means never lifting more than 5 lbs.

HOWEVER... HiRIT is not for everyone — some are fearful or uninterested. Dr. Beck's comment that Onero/HiRIT is the only approach that will help those with osteoporosis or low bone density is worrisome, since many people already feel discouraged and anxious, and implying that "if you can't do Onero, don't bother" risks adding to hopelessness. Joanne notes Dr. Beck was in the US promoting her now-commercially-available program, and while she'll always promote supervised HiRIT when appropriate, she also promotes other approaches such as Dr. Laura Giangregorio's Too Fit To Fracture Program; Dr. Giangregorio is also recruiting for a new "Fortify Bones" study to help determine optimal exercise intensity, "because we don't know what intensity of exercise is best."

Many researchers, including recent American Physical Therapy Association guidelines Joanne adheres to, have found a combination of exercise types is best. LaMonte and colleagues followed 77,206 postmenopausal women aged 50–79 (Women's Health Initiative) for over 5 years and found even mild activity and walking were associated with lower hip fracture risk — likely a bigger concern for most people than DXA T-scores. Katzman and colleagues demonstrated that posture-based exercises (many used in Strong Bones class) significantly improved postural alignment in 112 subjects, adding to the well-documented consensus linking better posture with fall prevention. Kitagawa and colleagues compared moderate- vs. high-intensity resistance/impact training (MiRIT vs. HiRIT) in postmenopausal osteoporotic women, finding HiRIT may achieve more significant lumbar spine BMD improvement, though "the certainty of evidence was extremely low because of the risk of bias, inconsistency among studies, and imprecision in terms of sample size."

The Takeaway. Exercise can improve bone metabolism/density, posture, balance, and fall prevention, making it a very effective non-pharmacologic approach even without always improving the DXA scan. Anything is better than nothing — but when ready, challenge yourself, whether through heavier weights, a longer/faster walk, or trying something new like a dance class.

Featured student testimonial (Lisa Widawsky): "Joanne Fagerstrom, PT stays abreast of research in her field and shares her vast knowledge – during exercise sessions, on her blog, in after-class Q&As, and in private consultations. She encourages progress beyond our current level of exercise intensity – when that is possible! – and suggests activities beyond what we do in class, e.g., 'exercise snacks' and other best practices. More intensive programs may require supervision, but the evidence-based Strong Bones program is completely safe – without supervision. Furthermore, the benefits of intensive exercise are not clear, especially for women over 50."

Dr. Beck is a Professor of Exercise Science at Griffith University in Queensland, Australia, and Director of The Bone Clinic, a research and clinical practice facility for osteoporosis patients.

References

1. Watson SL, et al. High-intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women with Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal of Bone and Mineral Research 2018;33:211-220.
2. Giangregorio LM, et al. Too Fit To Fracture: Outcomes of a Delphi Consensus Process on Physical Activity and Exercise Recommendations for Adults with Osteoporosis With or Without Vertebral Fractures. Osteoporosis International 2015 Mar;26(3):891-910.
3. Fortify Bones study, University of Waterloo Bone Health and Exercise Science Lab.
4. Hartley GW, et al. Physical Therapist Management of Patients With Suspected or Confirmed Osteoporosis. Journal of Geriatric Physical Therapy 2022 Apr-Jun;44(2):E106-E119.
5. Kast S, et al. Effects of Different Exercise Intensity on Bone Mineral Density in Adults: A Comparative Systematic Review and Meta-analysis. Osteoporosis International 2022 Mar 18.
6. LaMonte MJ, et al. Association of Physical Activity and Fracture Risk Among Postmenopausal Women. JAMA Network Open 2019 Oct 2;2(10):e1914084.
7. Katzman WB, et al. Long-Term Efficacy of Treatment Effects After a Kyphosis Exercise and Posture Training Intervention in Older Community-Dwelling Adults: A Cohort Study. Journal of Geriatric Physical Therapy 2021 Jul-Sep;44(3):127-138.
8. Kitagawa T, et al. A Comparison of Different Exercise Intensities for Improving Bone Mineral Density in Postmenopausal Women with Osteoporosis. Bone Reports 2022 Oct 21;17:101631.